Healthcare Provider Details

I. General information

NPI: 1043881139
Provider Name (Legal Business Name): JENNIFER MARIE GWAZDACZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5035 NE ELAM YOUNG PKWY STE 500
HILLSBORO OR
97124-6473
US

IV. Provider business mailing address

5035 NE ELAM YOUNG PKWY STE 500
HILLSBORO OR
97124-6473
US

V. Phone/Fax

Practice location:
  • Phone: 503-844-4325
  • Fax:
Mailing address:
  • Phone: 503-844-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number23917
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: